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OKLAHOMA CVS PHARMACY, L.L.C.
DSH370028 INTEGRIS BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
INTEGRIS BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370028
Entity Address
3300 NW EXPRESSWAY
OKLAHOMA CITY, OK 73112
Medicare Provider Number
370028
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OKLAHOMA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06231
4500 NW 23RD ST
OKLAHOMA CITY, OK 73127
Pharmacy Comments
Contract Details
Approval Date
4/14/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Johnsen, President
(405) 951-8110
Contract Pharmacy Representative
CVS
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
4/14/2013
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